Basic Information
| Provider Information | |||||||||
| NPI: | 1760879225 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLIVE CREST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2130 E 4TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145435437 | ||||||||
| FaxNumber: | 7145435463 | ||||||||
| Practice Location | |||||||||
| Address1: | 805-807 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912031230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186307480 | ||||||||
| FaxNumber: | 8185632342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | VERLEUR | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7145435437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OLIVE CREST | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7964 | 05 | CA | MEDICAID |